BACKGROUND AND OBJECTIVES: Bone flap infection and contamination are feared complications of cranial surgery, yet optimal management remains controversial. The aim of this review was to determine comparative outcomes of preservation with decontamination and reinsertion vs discard and replacement after intraoperatively contaminated or postoperatively infected bone flaps. METHODS: We systematically reviewed 70 studies (621 patients) reporting either intraoperatively contaminated or postoperatively infected flaps (PROSPERO: CRD420251041697). Patient demographics, decontamination protocols, replacement materials, and outcomes were extracted and synthesized. RESULTS: Three studies (49 patients) reported intraoperative contamination from dropped flaps, whereas 67 studies (572 patients) reported postoperative flap infections. Decontamination methods involved washing, scrubbing, and soaking with saline, povidone-iodine, peroxide or an antibiotic/antiseptic agent, and/or autoclaving, while replacement materials included titanium, polymethyl methacrylate, polyether ether ketone, or hydroxyapatite. Most patients achieved satisfactory cosmetic and neurological outcomes, with comparably low complication rates. None of the intraoperatively contaminated flaps developed postoperative infections after either approach. Preserved flaps carried significantly higher reoperation risk (absolute risk ratio 6.68%, odds ratio 2.948, 95% CI 1.450-5.993, P = .006). This means for every 15 patients treated with decontamination rather than replacement, one extra reoperation occurs. All reoperations occurred in patients with postoperatively infected flaps, most commonly because of severe recurrent infection. Comorbidities, for example, radiotherapy, immunosuppression, diabetes, and high body mass index, also emerged as a significant predictor of reoperation risk in logistic regression analysis (adjusted odds ratio 44.2, 95% CI 1.17-436, P = .0012). CONCLUSION: This is the largest pooled individual-patient data synthesis to date on management of contaminated or infected bone flaps. Both decontamination and replacement provide good outcomes and are safe and effective for intraoperatively contaminated flaps. However, decontamination with reinsertion carries higher reoperation risk compared with flap replacement among patients with postoperatively infected flaps. Flap preservation should therefore be undertaken selectively considering organism virulence, presence of purulence, and comorbidities. These results inform development of standardized risk-stratified guidelines and cost-effectiveness evaluation for bone flap management in cranial surgery.
Mirza et al. (Mon,) studied this question.